[Recurrent hernias after previous Shouldice operation]. / Die Rezidiv-Leistenhernie nach Shouldice-Voroperation.

For all 158 surgical operations performed on hernia recurrences throughout the period from March 2000 until the end of May 2001, we compared the intra-operative findings to the information contained in the operation reports--as far as available--as part of our quality management. In less than 20 % of the patients for whom a Shouldice repair had been documented in the operation reports, we found evidence of the actual performance of a Shouldice repair (typical cicatrised modifications on the rear wall or the fascia transversalis, sutures or residues of sutures). 74 % of the patients were treated with a Marlex(R) Perfix plug, avoiding the resection of stable cicatrisation fractions with incision of the rear wall in the case of an intact fascia. On 26 % of the patients it was possible to perform a Shouldice repair in compliance with the original technique. Meanwhile, mesh techniques have outpaced the Shouldice technique with respect to the recurrence rates in the efficiency statistics. This, however, is not caused by the technique as such, but rather by the fact that in many clinics the anatomical situations are obviously incorrectly assessed and/or that insufficient knowledge about suturing techniques prevails. As a consequence, worse results are reported for the Shouldice technique than for the mesh techniques. It is not the Shouldice technique that is insufficient but its performance suffers in many hospitals from substantial insufficiencies in terms of quality.

Management of gastroesophageal reflux disease in primary care: results of a survey in 2 areas in Germany.

BACKGROUND: The incidence of gastroesophageal reflux disease (GERD) is increasing. Although guidelines have been issued on the diagnosis and treatment of GERD, the way in which these should be applied in everyday practice is unclear. The aim of the present survey was to interview private-practice physicians on their personal opinions concerning the management of GERD. METHODS: A questionnaire based on the case of a typical patient with reflux was sent out to a total of 918 private-practice physicians. The questions concerned general measures for avoiding reflux symptoms (dietary and lifestyle modifications), the diagnosis of GERD, and the type and dosage of antireflux treatment. RESULTS: A total of 255 questionnaires were evaluated (28 %), which had been returned by 151 family doctors, 63 internal medicine specialists, and 41 gastroenterologists. 70 % of the respondents carry out specific diagnostic tests (endoscopy in 98 % of cases) prior to treatment. Altering specific dietary and lifestyle factors (such as sleeping position) was considered useful by the majority of respondents. 99 % of the physicians administer some form of GERD therapy, and 88 % of the internists/gastroenterologists and 74 % of family doctors (P = 0.006) do so using a "step-down" approach (with proton-pump inhibitors as the initial strategy). With the "step-up" procedure, the initial recommendation includes primarily antacids, with a change to more effective drugs only when symptomatic relief is not achieved. CONCLUSIONS: The current guidelines on the diagnosis and treatment of GERD are largely adhered to, particularly by specialists. In addition to the well-established drug treatment, empirical recommendations on dietary and lifestyle measures still form part of the management of GERD, despite the lack of scientific evidence to support them.